Preoperative biliary drainage in distal malignant biliary obstruction is considered to decrease jaundice prior to delayed curative surgery. Present rationale is biliary drainage using ERCP and biliary stenting. Some studies favours direct surgery rather than preoperative drainage, but have certain limitations. Biliary stenting can be done either with plastic or covered metal stent. However, covered metal stents have added advantages such as decrease risk of bleeding, pancreatitis, frequent stent block prior to surgery and are retrievable.

EUS-guided biliary drainage (EUS-BD) is an established alternative technique to unsuccessful endoscopic retrograde cholangio-pancreaticography (ERCP) in patients with malignant biliary obstruction.  Recent study establishes the short term outcome and complications comparable between EUS-BD and ERCP. In addition complication like pancreatitis was frequent in ERCP than EUS-BD.   Among different methods of EUS guided biliary drainage, EUS guided hepatogastric stenting  (EUS-HGS) showed more technical and clinical success with comparable complication rate. EUS-HGS has certain advantages over conventional biliary drainage. Firstly challenging step of antigrade guidewire passage both in rendezveous & antegrade stenting is avoided. Secondly, it is more physiological in patients with altered anatomy (congenital or altered) as it requires less repeated puncture.